WHITE PAPER FH Healthcare Indicators and FH Medical Price Index 2019 - An Annual View of Place of Service Trends and Medical Pricing - Amazon S3

 
WHITE PAPER FH Healthcare Indicators and FH Medical Price Index 2019 - An Annual View of Place of Service Trends and Medical Pricing - Amazon S3
WHITE PAPER

      FH Healthcare Indicators® and
      FH Medical Price Index® 2019
An Annual View of Place of Service Trends and Medical Pricing

                                                       A FAIR Health White Paper, April 2019

             Copyright 2019, FAIR Health, Inc. All rights reserved.
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Summary
This is the second annual edition of FH Healthcare Indicators® and the FH Medical Price Index®, two
resources developed by FAIR Health to provide clarity in a rapidly changing healthcare environment.
Drawing on the independent nonprofit’s national database of billions of privately insured healthcare
claims—the largest in the country—these two resources apply different approaches to illuminate different
aspects of the national healthcare sector.

FH Healthcare Indicators analyze trends involving the place of service for healthcare in recent years.
Focusing on alternative places of service—retail clinics, urgent care centers, telehealth and ambulatory
surgery centers (ASCs)—as well as emergency rooms (ERs), FH Healthcare Indicators evaluate changes
in utilization, geographic and demographic factors, diagnoses, procedures and costs. In the new edition,
all time frames advance one year forward from the previous edition. For example, if a chart last year
showed usage trends from 2011 to 2016, this year’s chart shows 2012 to 2017. These are some of the
key findings:

        From 2016 to 2017, national utilization of telehealth grew 53 percent, more than any other place
         of service studied for that variable in this report. By comparison, utilization of urgent care centers
         increased 14 percent, retail clinics 7 percent and ASCs 6 percent, while that of ERs decreased 2
         percent.
        From 2016 to 2017, retail clinic utilization decreased 28 percent in urban areas, while rural
         utilization grew 3 percent. But in the same period, urgent care center utilization increased 15
         percent in urban areas while remaining flat in rural areas (0 percent).
        Nationally in 2017, the percentage of all medical claim lines attributed to retail clinics was less
         than 0.1 percent, that attributed to urgent care centers more than 1 percent and that attributed to
         ERs more than 2 percent.
        In 2017, as in 2016, claim lines were submitted for women more than men in all adult age groups
         in the places of service in which FAIR Health studied gender-related patterns—retail clinics,
         urgent care centers, telehealth, ASCs and ERs.
        The most common diagnostic category in 2017 in retail clinics and urgent care centers, and
         among individuals over 22 years of age in the ER, was acute respiratory infections. But for
         individuals 22 and younger in the ER, digestive system issues were the number one diagnostic
         category.
        Mental health reasons, which had been the number one diagnostic category for telehealth in
         2016, were number five in 2017, at seven percent of the distribution of claim lines. Telehealth
         expanded in usage; for example, injury made up 13 percent of telehealth diagnoses in 2017.
        Pediatric and young adult age groups made up larger shares of the distribution of claim lines with
         telehealth usage in 2017 than in the previous year. For example, the age group 0-10 constituted 4
         percent of the distribution in 2016 but 10 percent in 2017.
        In 2017, the median charge amount for a 30-minute new patient office visit (CPT ®1 99203) ranged
         from $213 in an urgent care center to $207 in an office to $129 in a retail clinic.

The FH Medical Price Index tracks the growth in median procedure charges and median imputed allowed
amounts2 in six procedure categories. This report does not consider facility fees. The categories are:

        Professional evaluation and management (E&M; excluding E&Ms performed in a hospital setting);

1 CPT © 2018 American Medical Association (AMA). All rights reserved.
2 Because payors’ contracted network rates are proprietary and cannot be shared, FAIR Health employs an
imputation methodology to determine benchmarks for allowed amounts. First, FAIR Health calculates the ratios of
actual allowed amounts to charges for groups of procedure codes on a regional basis. The resulting ratios are applied
to the actual charges for each specific procedure at the local (geozip) level to develop an “imputed” allowed amount
for each claim line.

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   Hospital E&M (excluding E&Ms performed in a professional setting, such as typical office visits);
       Medicine (excluding E&Ms);
       Surgery (procedures for which the physician would bill);
       Pathology and laboratory (including both technical and professional components, e.g., both
        equipment and physician services); and
       Radiology (including both technical and professional components).

May 2012 is the base month, to which values in later periods are compared; therefore, the FH Medical
Price Index establishes a consistent point of reference that makes it easy to identify and compare shifts.

In the first edition, the FH Medical Price Index presented an overview from May 2012 to May 2017. In the
new edition, the indices are extended to November 2018. Findings include the following, all for the period
November 2017 to November 2018:

       Of the six categories, hospital E&Ms had the greatest percent increase in charge amount index,
        seven percent. Hospital E&Ms and radiology had the greatest percent increase in allowed amount
        indices, both seven percent. The radiology charge amount index grew six percent.
       The professional E&M charge amount index increased four percent and allowed amount index
        three percent.
       The medicine charge amount index grew four percent and allowed amount index three percent.
       The surgery charge amount and allowed amount indices each grew six percent.
       The pathology and laboratory charge amount and allowed amount indices each increased three
        percent.

Background
In a white paper in March 2018, FAIR Health launched two new sources of healthcare information: FH
Healthcare Indicators® and the FH Medical Price Index®.3 Designed to provide clarity in a rapidly changing
healthcare environment, these two resources for deriving insights from data elicited a welcome public
response; stakeholders expressed appreciation for being offered this “macro” view into the nation’s
healthcare system. From the start, the resources were intended to be released annually to keep pace with
change. This is the second annual edition.

Since the first edition, the healthcare sector has continued to change and grow more complex. Healthcare
stakeholders continue to need information that will enable them to discern fundamental trends and
patterns, and to make decisions on that basis. FH Healthcare Indicators and the FH Medical Price Index
are intended to serve all such constituents, including insurers and companies that self-insure, third-party
administrators, hospitals and health systems, physicians and other individual providers, pharmaceutical
and device manufacturers, federal and state government officials, legislators, policy makers, economists
and academic researchers.

In response to the ongoing growth of alternative places of service, FH Healthcare Indicators examine
recent trends in such venues of care—including retail clinics, urgent care centers, telehealth and
ambulatory surgery centers (ASCs)—as well as traditional emergency rooms (ERs). Areas of analysis
include utilization, geographic and demographic factors, diagnoses, procedures and costs. In the new
edition, all time frames advance one year forward from the previous edition. For example, if a chart last
year showed usage trends from 2011 to 2016, this year’s chart shows 2012 to 2017. The new edition

3FAIR Health, FH Healthcare Indicators™ and FH Medical Price Index™: A New View of Place of Service Trends
and Medical Pricing, A FAIR Health White Paper, March 2018,
https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/FH%20Medical%20Price%20Index%20and%20F
H%20Healthcare%20Indicators--whitepaper.pdf.

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includes new growth charts in which utilization of a place of service in rural, urban and national settings is
shown as a percentage of all medical claim lines in that setting.

The FH Medical Price Index presents a multiyear overview of the weighted average growth in median
charges and median allowed amounts for professional evaluation and management (E&M), hospital E&M,
medicine, surgery, pathology and laboratory, and radiology categories. In the first edition, the FH Medical
Price Index presented an overview from May 2012 to May 2017. In the new edition, the indices are
extended to November 2018.

Both FH Healthcare Indicators and the FH Medical Price Index are powered by the same source: FAIR
Health’s database of over 28 billion claim records contributed by payors and administrators who insure or
process claims for private insurance plans covering more than 150 million individuals. A national,
independent, nonprofit organization, FAIR Health uses this repository—the nation’s largest collection of
private healthcare claims data—in furtherance of its mission of bringing transparency and integrity to
healthcare costs and health insurance information.

Like the inaugural release, this year’s edition of FH Healthcare Indicators and the FH Medical Price Index
is intended to assist healthcare stakeholders in a variety of ways. For example, investors can use the
information in researching the healthcare sector; health systems in budgeting and considering affiliations
or market expansion; insurers in designing plan benefits and setting premiums; government agencies and
policy makers in trying to set courses to benefit the public good; and economists and researchers in
seeking to track and evaluate important trends.

Methodology
FH Healthcare Indicators Methodology
To segregate FAIR Health claims data into venues of care, FAIR Health used standard Centers for
Medicare & Medicaid Services (CMS) Place of Service codes to identify retail clinics (CMS Place of
Service 17), urgent care centers (CMS Place of Service 20) and office (CMS Place of Service 11). Other
methodologies were used to identify ERs (e.g., CMS Place of Service 23, Bill Type of 131 and/or an
emergency department visit CPT code [CPT 99281, CPT 99282, CPT 99283, CPT 99284, CPT 99285]);
telehealth (telehealth CPT codes such as CPT 99441 [telephone evaluation and management service
provided by a physician to an established patient] or telehealth modifiers such as GQ); and ASCs (Bill
Type of 83* or CMS Place of Service 24). The data were then aggregated by a variety of key fields,
including state, urban/rural, diagnostic categories (e.g., urinary tract infection, ear infection, acute
respiratory infections), year of service and patient demographics (age and gender), to identify trends and
patterns in utilization and variation in cost. The data were evaluated with single and multiple variables to
look for distinct trends and associations, which were then used to create graphical representations of the
information.

In the graphical representations, the term “claim lines” refers to the individual procedures listed on
insurance claims. A single claim for one patient may have multiple claim lines. To normalize the data and
avoid fluctuations due to natural changes within plan data (e.g., the closing of a major retailer and the loss
of those members, or the addition of a major employer to a plan from which FAIR Health receives data,
which would create a net influx of data from those members), FAIR Health calculates each data point as a
percentage of the total number of medical claim lines. When evaluating rural or urban data for a place of
service, the denominator is all medical claim lines within that year and region. When evaluating total
national data for a place of service, the entirety of medical claim lines for that year is the denominator.
Once this claim line percentage is established, FAIR Health creates two separate types of trend charts.

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“Percent of claim lines” (figures 1, 9, 19, 25, 28) is the percentage of all normalized claim line
percentages as described above associated with a given grouping (e.g., a place of service) in a given
time period in a particular chart. For example, in figure 1, which shows claim lines with retail clinic usage
by rural, urban and national settings from 2012 to 2017, each year’s data point for national usage is the
percentage of all the claim lines in the national usage grouping from 2012 to 2017. If one were to add up
all the data points for national usage from all the years in this period, they would total 100 percent.

Other graphs present “percent of all medical claim lines” (figures 2, 10, 20, 26, 29). In this case, the
number of claim lines for the place of service being evaluated in a particular location (state, rural, urban or
national) in a particular year is presented as a percentage of all claim lines within the FAIR Health
database that are designated as medical claim lines (not including dental or pharmacy claim lines) in that
location in that year. For example, in figure 2, rural retail clinic claim lines in 2012 are shown as a
percentage of all rural medical claim lines in that year.

FH Medical Price Index Methodology
FAIR Health used two of its benchmark modules, FH® Medical and FH® Allowed Medical, to calculate,
respectively, charge amounts and allowed amounts for the FH Medical Price Index. For each procedure
code, the benchmark products report a median value, which is the dollar value used for all codes included
in the indices. Fourteen releases of the benchmark products were used to establish the indices: May and
November of each year from 2012 to 2018. The total frequency for each procedure code within the
selected categories (professional E&M, hospital E&M, medicine, surgery, pathology and laboratory, and
radiology) was used to select codes for inclusion or exclusion. Each procedure code in a category that
had a total combined frequency of one million or more occurrences in the 14 module releases was
included in the indices. This allowed for natural inclusion of new codes and eventual exclusion of deleted
codes in a gradual and controlled manner so as not to create erroneous fluctuations.

Once the list of codes to be included in the index was established, the median value for each release for
each code (in dollars) was multiplied by the corresponding frequency for that code for the 14 releases,
producing the release code median total. Then, all release code median totals in a category were
summed to get a total dollar value for each release in that category (the release median total). That
release median total was divided by the total frequency to generate a release average median. Each
index was then created by using the following index formula: dividing each release average median for
each month and year by the first release average median established (May 2012, the base):

        Release Weighted Average of MedianMONTH YEAR
        ------------------------------------------------------------------- = Index ValueMONTH YEAR
        Release Weighted Average of MedianBASE

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A sample calculation of how an FH Medical Price Index value is derived is given in the table below.

Table. Calculation of FH Medical Price Index for professional E&M charge amounts over a sample
of the period May 2012-November 2018

                                                           Release
                                                           Median                       FH
                                                           Total/Total                  Medical
                                                                       Index
Release Release Median Total Total Frequency               Frequency =                  Price
                                                                       Formula
                                                           Release                      Index
                                                           Average                      Value
                                                           Median

May                                                        $139.07           $139.07
2012
             $280,020,108,863           2,013,522,941                       (          ) 1.00
                                                           (base)            $139.07

Nov                                                                          $177.63
2018
             $411,408,329,254          2,316,139,866       $177.63          (          ) 1.28
                                                                             $139.07

FH Healthcare Indicators
As in last year’s report, FAIR Health studied four alternative places of service—retail clinics, urgent care
centers, telehealth and ASCs—and compared them to more traditional venues of care, offices and ERs.
This year, the findings were brought up to date through 2017. Because venues of care are subject to
varying state laws and regulations, changes in utilization may reflect greater liberalization or constraints
associated with the relevant venue. For example, in Texas, a law passed in 2017, which enabled
healthcare providers to establish a physician-patient relationship by telehealth without an initial face-to-
face meeting, was expected to increase the potential of telehealth utilization in that state.4,5 In
Massachusetts, regulations created in 2008 restricted the services retail clinics could provide, though
those services were later expanded by a 2012 law.6,7

4 Joey Berlin, “Clearer and Simpler,” Texas Medicine 113, no. 7 (2017): 38-39,
https://www.texmed.org/Template.aspx?id=45337.
5 Eric Wicklund, “With New Texas Law, Telemedicine Passes an Important Milestone,” mHealth Intelligence, May 31,

2017, https://mhealthintelligence.com/news/with-new-texas-law-telemedicine-passes-an-important-milestone.
6 “Retail Health Clinics: State Legislation and Laws,” National Conference of State Legislatures, August 1, 2017,

http://www.ncsl.org/research/health/retail-health-clinics-state-legislation-and-laws.aspx.
7 Antoinette Alexander, “Mass. Lawmakers Pass Healthcare Bill That Expands Use of Limited-Service Clinics,” Drug

Store News, August 1, 2012, https://www.drugstorenews.com/news/mass-lawmakers-pass-healthcare-bill-expands-
use-limited-service-clinics/.

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Retail Clinic
Claim lines for retail clinics grew overall 674 percent from 2012 to 2017, a slower pace of growth than that
documented in last year’s report (847 percent from 2011 to 2016; figure 1). Growth from 2012 to 2017
was similar in rural (655 percent) and urban areas (656 percent). From 2016 to 2017, total growth in retail
clinic utilization was seven percent.

Retail clinic utilization in urban areas increased more than in rural areas from 2015 to 2016, but from
2016 to 2017 that trend was replaced by a decrease of 28 percent in urban areas, while rural utilization
remained steady at 3 percent growth.

As noted in the Methodology section, actual claim lines in our database may have increased with respect
to a particular venue even when a chart shows a comparative decrease year to year, because FAIR
Health normalizes data by calculating each data point as a percentage of the total number of medical
claim lines for a particular year. That is, while actual claim lines for a venue may increase in one year as
compared to another, the percentage of claim lines associated with that particular venue may have
decreased when juxtaposed against all claim lines used as the denominator for the analysis, which may
increase or decrease from year to year.

                            35%

                            30%

                            25%
   Percent of claim lines

                            20%

                            15%

                            10%

                            5%

                            0%
                                  2012    2013           2014            2015                2016   2017
                                                                Year

                                           Rural        Urban          Retail Clinic Total

Figure 1. Percent of claim lines with retail clinic usage by rural, urban and national settings, 2012-
2017

                                         FH Healthcare Indicators and FH Medical Price Index 2019          7
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For an added perspective to improve understanding of healthcare trends, this year’s edition of FH
Healthcare Indicators includes a second view of place of service growth trends. In figure 1 above, rural
and urban retail clinic usage in 2012 is shown as a percentage of all rural and urban retail clinic usage,
respectively, from 2012 to 2017. But in figure 2 below, rural and urban retail clinic usage in 2012 is shown
as a percentage of all rural and urban medical claim lines, respectively, in that year.

In rural, urban and national settings from 2012 to 2017, the percentage of all medical claim lines
attributed to retail clinics was less than 0.1 percent. In rural areas, the percentage grew from 0.006
percent in 2012 to 0.045 percent in 2017. In urban areas, the percentage grew from 0.004 percent to
0.032 percent; in the nation as a whole, the increase was from 0.004 percent to 0.033 percent. In all
years except 2016, rural retail clinic usage was a larger percentage of all medical claim lines in the rural
setting than urban retail clinic usage was in the urban setting.

                                                         0.050%

                                                         0.045%
   Percent of all medical claim lines for that setting

                                                         0.040%

                                                         0.035%

                                                         0.030%

                                                         0.025%

                                                         0.020%

                                                         0.015%

                                                         0.010%

                                                         0.005%

                                                         0.000%
                                                                  2012        2013           2014            2015              2016   2017
                                                                                                     Year

                                                                              Rural        Urban         Retail Clinic Total

Figure 2. Claim lines with retail clinic usage as a percentage of all medical claim lines by rural,
urban and national settings, 2012-2017

                                                                         FH Healthcare Indicators and FH Medical Price Index 2019            8
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In the heat map below, states in which claim lines with retail clinic usage were a greater percentage of all
medical claim lines than other states in 2017 are on the red end of the spectrum, while states with a lower
percentage are on the green end (figure 3). Minnesota was the number one state for claim lines with a
high percentage of retail clinic usage. Legislation and regulation can influence the spread of retail clinics.
The site of the first retail clinic,8 Minnesota has been receptive to the growth of these places of service.

The other four states in the top five for retail clinic usage in 2017, in order from most to least, were New
York, New Jersey, Nebraska and Alaska. The five states with the lowest usage, in order from least to
most, were California, Utah, Nevada, Iowa and Colorado.

Figure 3. Percent of claim lines with retail clinic usage compared to all medical claim lines by
state, 2017

8Christopher M. Burkle, “The Advance of the Retail Health Clinic Market: The Liability Risk Physicians May
Potentially Face When Supervising or Collaborating with Other Professionals,” Mayo Clin Proc 86, no. 11 (2011):
1086-91, https://doi.org/10.4065/mcp.2011.0291.

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As in 2016, the greatest number of claim lines with retail clinic usage in 2017 was submitted for
individuals aged 51 to 60, who accounted for 23 percent of all such claim lines, nearly the same as the
previous year’s 24 percent (figure 4). As in the previous year, the 61-70 age group had the second
greatest percentage of claim lines, increasing from 17 percent in 2016 to 20 percent in 2017. There were
also increases in the percentage of claim lines for individuals over 70 and decreases for individuals aged
23 to 40.

                             25%

                             20%
    Percent of claim lines

                             15%

                             10%

                             5%

                             0%
                                   0 to 10 11 to 18 19 to 22 23 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 Over 80
                                                                         Age group

Figure 4. Claim lines with retail clinic usage by age group, 2017

                                                  FH Healthcare Indicators and FH Medical Price Index 2019                   10
In 2017, as in 2016, claim lines were submitted for women more than men in all adult age groups in the
places of service in which FAIR Health studied gender-related patterns—retail clinics, urgent care
centers, telehealth, ASCs and ERs. This is consistent with the findings of other researchers that women
are more likely than men to visit physicians9 and make use of healthcare services.10 In 2017, from age 19
to 40, retail clinic claim lines for women outnumbered those for men by approximately 70 percent to 30
percent, respectively (figure 5). As in 2016, the one age group in which claim lines for males
outnumbered those for females was that of children aged 0 to 10.

                 Over 80
                 71 to 80
                 61 to 70
                 51 to 60
     Age group

                 41 to 50
                 31 to 40
                 23 to 30
                 19 to 22
                 11 to 18
                  0 to 10

                            0%   10%        20%        30%        40%        50%        60%        70%        80%
                                                          Pecent of claim lines

                                                         Male    Female

Figure 5. Claim lines with retail clinic usage by age and gender, 2017

9 Jill J. Ashman, Esther Hing and Anjali Talwalkar, “Variation in Physician Office Visit Rates by Patient Characteristics
and State, 2012,” NCHS Data Brief, no. 212 (Hyattsville, MD: National Center for Health Statistics, 2015),
https://www.cdc.gov/nchs/data/databriefs/db212.pdf.
10 Klea D. Bertakis et al., “Gender Differences in the Utilization of Health Care Services,” J Fam Pract 49, no. 2

(2000):147-52, https://www.ncbi.nlm.nih.gov/pubmed/10718692.

                                       FH Healthcare Indicators and FH Medical Price Index 2019                       11
The most common diagnostic category in retail clinics was acute respiratory infections, which accounted
for 34 percent of the distribution of claim lines with retail clinic usage in 2017 (figure 6). That was the most
common diagnostic category in retail clinics in 2016 as well, though the percentage in 2017 was larger
than the previous year (24 percent). The second most common diagnostic category in 2017, exposure to
communicable diseases (12 percent), was in third place the year before, behind general symptoms.

Other common diagnostic categories in retail clinics in 2017 included ear infections (six percent),
encounter for examination (six percent) and urinary tract infections (five percent).

                    Influenza and    All Others
                                        18%
Chronic Respiratory Pneumonia
    Infections            3%
                                                                                            Acute Respiratory
        3%                                                                                     Infections
                                                                                                  34%

 Mental Health
   Disorder
     3%

  Dermatological Issue
         5%

General Symptoms
       5%

           Urinary Tract
            Infections                                                                Exposure to
                5%                                                                   Communicable
                           Encounter for                                               Diseases
                           Examination             Ear Infection                         12%
                               6%                       6%

Figure 6. Distribution of claim lines with retail clinic usage by diagnostic category, 2017

                               FH Healthcare Indicators and FH Medical Price Index 2019                      12
The type of procedure most commonly performed in retail clinics in 2017 was established patient office or
other outpatient services (29 percent of retail clinic claim lines; figure 7). This was the top procedure in
2016 as well, at 26 percent. The rest of the top five procedures in 2017 were new patient office or other
outpatient services (13 percent), infectious agent antigen detection (e.g., flu, streptococcus; 12 percent),
vaccines and toxoids (e.g., flu vaccine; tetanus, diphtheria and pertussis vaccine [Tdap]; 7 percent) and
immunization administration for vaccines/toxoids (6 percent).

                     All Others
                                                                                               Established Patient
                        20%
                                                                                                 Office or Other
Patient History                                                                                Outpatient Services
     2%                                                                                                29%

Drugs Administered
 Other Than Oral
       3%

Urinalysis Procedures
          3%

Private Payer Codes
         5%
                                                                                             New Patient Office or
                                                                                               Other Outpatient
 Immunization                                                                                     Services
Administration for                                                                                   13%
Vaccines/Toxoids
      6%
                 Vaccines, Toxoids                                        Infectious Agent
                        7%                                               Antigen Detection
                                                                                 12%

Figure 7. Distribution of claim lines with retail clinic usage by procedures, 2017

                                  FH Healthcare Indicators and FH Medical Price Index 2019                       13
The average charges and allowed amounts for the most common procedures performed in retail clinics in
2017, as identified by CPT code, are shown in figure 8. Office visits, such as CPT 99213, 99202, 99203
and 99214, which are established and new patient visits with varying times, had national average charges
in a retail clinic ranging from $147 (for CPT 99203, a 30-minute new patient visit) to $105 (for CPT 99213,
a 15-minute established patient visit). The average allowed amounts were $99 and $78, respectively, for
those procedures.

Streptococcus tests (CPT 87880) were associated with an average charge of $33 and an average
allowed amount of $16. Vaccinations were billed, on average, from $32 (CPT 90471, immunization
administration) to $30 (CPT 90686, flu vaccine) with corresponding allowed amounts of $20 each.

                       $160                                         $147                     $146
                       $140                            $127
                                                                           $99                      $100
      Average amount

                       $120   $105
                                                              $85
                       $100          $78
                       $80
                       $60                                                                                 $38
                                           $33                                   $32                             $18   $30 $20
                       $40                       $16                                   $20
                       $20
                         $0
                              99213        87880       99202        99203    90471           99214         87804       90686
                                                                       CPT code

                                           Average Charge Amount             Average Allowed Amount

CPT                                                                   CPT
Code                    Description                                   Code        Description
99213     Office outpatient visit - 15 minutes 90471 Immunization administration
87880     Streptococcus test                   99214 Office outpatient visit - 25 minutes
99202     Office outpatient - new - 20 minutes 87804 Influenza test
99203     Office outpatient - new - 30 minutes 90686 Influenza virus vaccine, quadrivalent
Figure 8. Average charges and average allowed amounts for the most common procedures
performed in retail clinics, 2017

                                            FH Healthcare Indicators and FH Medical Price Index 2019                             14
Urgent Care
As shown in figure 9, claim lines for urgent care centers grew overall 1,434 percent from 2008 to 2017.
The increase was lower than from 2007 to 2016, as documented in last year’s report (1,725 percent).
Growth in urgent care center usage from 2008 to 2017 was overall higher in rural (1,618 percent) than
urban areas (1,419 percent). But from 2016 to 2017, growth was flat in rural areas (0 percent) compared
to urban areas (15 percent); overall growth in that period was 14 percent.

                            20%

                            18%

                            16%

                            14%
   Percent of claim lines

                            12%

                            10%

                            8%

                            6%

                            4%

                            2%

                            0%
                                  2008   2009      2010      2011      2012          2013     2014       2015   2016   2017
                                                                              Year

                                                     Rural          Urban            Urgent Care Total

Figure 9. Percent of claim lines with urgent care center usage by rural, urban and national
settings, 2008-2017

                                                FH Healthcare Indicators and FH Medical Price Index 2019                      15
Figure 10 presents claim lines with urgent care center usage as a percentage of all medical claim lines by
rural, urban and national settings. Unlike figure 2, which showed that the percentage of all medical claim
lines attributed to retail clinics in rural, urban and national settings throughout the period 2012-2017 was
less than 0.1 percent, figure 10 shows that the percentage attributed to urgent care centers reached over
1 percent in all three settings by 2017. In rural areas, the percentage grew from 0.01 percent in 2008 to
1.3 percent in 2017. In urban areas, the percentage grew from 0.01 percent to 1.2 percent. In the nation
as a whole, the increase was from 0.01 percent to 1.2 percent.

Although urgent care center claim lines were a greater percentage of all medical claim lines in rural than
urban settings in 2017, the gap between the two closed partially since 2016. In 2016, the rural percentage
was 1.3 percent compared to 1.0 percent for urban; in 2017, the rural percentage was 1.3 percent
compared to 1.2 percent for urban.

                                                         1.4%
   Percent of all medical claim lines for that setting

                                                         1.2%

                                                         1.0%

                                                         0.8%

                                                         0.6%

                                                         0.4%

                                                         0.2%

                                                         0.0%
                                                                2008   2009     2010      2011      2012          2013    2014        2015   2016   2017
                                                                                                           Year

                                                                                  Rural          Urban            Urgent Care Total

Figure 10. Claim lines with urgent care center usage as a percentage of all medical claim lines by
rural, urban and national settings, 2008-2017

                                                                              FH Healthcare Indicators and FH Medical Price Index 2019                     16
In 2017, the top five states for claim lines with urgent care center usage as a percentage of all medical
claim lines in that state, in order from most to least, were Hawaii, Louisiana, New Mexico, Maryland and
Virginia (figure 11). In 2016, all but Maryland and Virginia were in the top five, along with West Virginia
and Rhode Island.

The bottom five jurisdictions for claim lines with urgent care center usage as a percentage of all medical
claim lines in 2017, in order from least to most, were North Dakota; Washington, DC; Iowa;
Massachusetts; and Alaska. All but Massachusetts were in the bottom five in 2016, along with South
Dakota.

Figure 11. Percent of claim lines with urgent care center usage compared to all medical claim lines
by state, 2017

                              FH Healthcare Indicators and FH Medical Price Index 2019                    17
As in 2016, the greatest number of claim lines with urgent care center usage in 2017 was submitted for
individuals aged 31-40 (18 percent both years; figure 12). This differed from the peak age group for retail
clinics, which was 51-60 both years (figure 4). Pediatric patients (individuals 18 years and younger)
accounted for 22 percent of urgent care center claim lines in 2017, a larger share than in retail clinics (8
percent). This is likely due to legislative restrictions in certain states that do not allow some pediatric
patients to see a retail clinic provider.

                             18%

                             16%

                             14%
    Percent of claim lines

                             12%

                             10%

                             8%

                             6%

                             4%

                             2%

                             0%
                                   0 to 10 11 to 18 19 to 22 23 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 Over 80
                                                                          Age group

Figure 12. Claim lines with urgent care center usage by age group, 2017

                                                  FH Healthcare Indicators and FH Medical Price Index 2019                   18
In 2017, as in 2016, urgent care center claim lines for females exceeded those for males in every age
group except 0-10 (figure 13). This was the same pattern observed in retail clinics in those years (figure
5). In urgent care centers, the greatest gender disparity was in the age group 19-22, in which claim lines
for women outnumbered those for men by 63 percent to 37 percent.

                Over 80

                71 to 80

                61 to 70

                51 to 60
    Age group

                41 to 50

                31 to 40

                23 to 30

                19 to 22

                11 to 18

                 0 to 10

                           0%   10%       20%          30%            40%      50%           60%   70%
                                                     Percent of claim lines

                                                    Male     Female

Figure 13. Claim lines with urgent care center usage by age and gender, 2017

                                  FH Healthcare Indicators and FH Medical Price Index 2019               19
As in retail clinics (figure 6), and as in 2016, acute respiratory infections were the most common
diagnostic category in urgent care centers, accounting for 31 percent of claim lines in that place of service
in 2017 (figure 14). As in the previous year, general symptoms, such as headache, fever or general
malaise, were the second most common diagnostic category, with 18 percent of the distribution. Sprains,
strains, breaks and fractures accounted for nine percent of claim lines, and joint/soft tissue issues,
including dorsopathies, arthropathies and various arthritis concerns, for seven percent. Claim lines for
urinary tract infections, injuries (other than breaks and strains) and ear infections each constituted five
percent of the distribution.

        Chronic Respiratory Eye Disorders and
               Issues           Infections
                 2%                 2%
         Skin Infection                       All Others
              4%                                  8%
                                                                                   Acute Respiratory
  Influenza/Pneumonia                                                                 Infections
           4%                                                                            31%
           Ear Infection
                5%

               Injuries
                 5%

            Urinary Tract
              Infection
                 5%
                     Joint/Soft Tissue                                            General Symptoms
                          Issues                                                        18%
                            7%             Sprains, Strains,
                                         Breaks and Fractures
                                                 9%

Figure 14. Distribution of claim lines with urgent care center usage by diagnostic category, 2017

                               FH Healthcare Indicators and FH Medical Price Index 2019                   20
As in retail clinics (figure 7), and as in 2016, established patient office or other outpatient services were
the most common procedure in urgent care centers, accounting for 23 percent of the claim line
distribution for that place of service in 2017 (figure 15). With urgent care visits (18 percent) and new
patient office or other outpatient services (15 percent), these procedures accounted for 56 percent of all
codes billed for an urgent care visit. Infectious agent antigen detection made up 10 percent of the
distribution. Drugs administered other than oral (including anti-inflammatory injections and antibiotics) and
urinalysis each constituted four percent.

                                   New Patient Office or
                                     Other Outpatient         Infectious Agent Drugs Administered     Urinalysis
                                        Services             Antigen Detection  Other Than Oral          4%
                                           15%                       10%              4%
                                                                                                    Miscellaneous
                                                                                                      Services
          Urgent Care Visit                                                                              3%
               18%                                                                                  Injections and
                                                                                                       Infusions
                                                                                                          3%
                                                                                                Pulmonary Testing
                                                                                                  and Therapies
                                                                                                        2%
                                                                                                  Diagnostic Rad
                                                                                                 Lower Extremities
                                                                                                         2%
           Established Patient
                                                               All Others                             Diagnostic
             Office or Other
                                                                  11%                                 Rad Chest
           Outpatient Services
                   23%                                                                    Venipuncture 2%
                                                                                              1%
                                                                   Inhalation Solutions
                                                                            1%                    Diagnostic Rad
                                                                                                 Upper Extremities
                                                                                                       1%

Figure 15. Distribution of claim lines with urgent care center usage by procedures, 2017. “Rad” is
“radiology.”

                                 FH Healthcare Indicators and FH Medical Price Index 2019                          21
As in 2016, the average charges and average allowed amounts for many of the most common
procedures in urgent care centers in 2017 were higher than in retail clinics (figure 16). This may be
because urgent care centers need the technological capacity to treat more serious conditions than retail
clinics, such as fractures. It may also be because an urgent care center must pay all of its own facility
costs, such as rent, whereas retail clinics often share space inside a larger facility, such as a drugstore or
supermarket.

In urgent care centers, office visits had national average charges from $308 (for CPT 99204, a 45-minute
new patient visit) to $166 (for CPT 99213, a 15-minute visit) and, respectively, average allowed amounts
from $168 to $98 for those same visits. By comparison, the average charge in a retail clinic for CPT
99213 was $105 and the average allowed amount $78 (figure 8). The average charge for S9083, a global
urgent care fee that covers all procedures within the urgent care setting, was $234; the average allowed
amount was $152.

    $350
                                                                   $308
    $300
             $234      $224                    $227
    $250
                                                                          $168
    $200            $152          $166
                              $129                    $135
    $150                                 $98
    $100
                                                                                         $58         $54         $55
                                                         $42 $14             $46               $30
                                                                                   $16                     $19         $27
     $50

        $0
             S9083     99214     99213         99203     87880     99204     87804       96372       99051       S9088

                                 Average Charge Amount             Average Allowed Amount

CPT/HCPCS                                                CPT/HCPCS
Code      Description                                    Code      Description
S9083         Global fee urgent care centers             99204        Office outpatient - new - 45 minutes
99214         Office outpatient visit - 25 minutes       96372        Therapeutic, prophylactic or diagnostic injection
99213         Office outpatient visit - 15 minutes       87804        Flu test
                                                                      Regularly scheduled evening, weekend or holiday office
99203         Office outpatient - new - 30 minutes 99051              hours
87880         Streptococcus test                         S9088        Services provided in an urgent care center
Figure 16. Average charges and average allowed amounts for the most common procedures
performed in urgent care centers, 2017

Retail Clinic, Urgent Care Center and Office: A Price Comparison
For a comparison of prices at retail clinics, urgent care centers and traditional offices, FAIR Health
analyzed claims data for new patient E&M codes. A new patient E&M visit includes a detailed history for
the patient, a detailed examination and medical decision making. Counseling and coordination of care
with other providers also may occur. The visits are coded by length of time: CPT 99202 is 20 minutes,
CPT 99203 is 30, CPT 99204 is 45 and CPT 99205 is 60.

                                 FH Healthcare Indicators and FH Medical Price Index 2019                                    22
Figure 17 shows how the median charge amounts varied by place of service in 2017. CPT 99202 ranged
from $160 in an urgent care center to $138 in an office to $104 in a retail clinic. CPT 99203 ranged from
$213 in an urgent care center to $207 in an office to $129 in a retail clinic. CPT 99204 and CPT 99205
were not billed frequently enough in retail clinics to have established values. But in offices, the median
charge amount for CPT 99204 was higher ($312) than in urgent care centers ($294). For CPT 99205, the
median charge amount was the same ($400) for those two places of service.

                                                                                                           $400     $400

                            $400
                                                                                      $312
                            $350                                                             $294
     Median charge amount

                            $300
                                                                $207 $213
                            $250
                                              $160
                            $200       $138                                   $129
                                                      $104
                            $150

                            $100

                            $50

                              $0
                                         99202                        99203             99204*                  99205*
                                                                              CPT procedure code

                                                             Office     Urgent Care   Retail Clinic

CPT Code                           Description
99202          Office outpatient – new – 20 minutes
99203          Office outpatient – new – 30 minutes
99204          Office outpatient – new – 45 minutes
99205          Office outpatient – new – 60 minutes
* Retail clinics did not have enough volume to establish any values for CPT 99204 or CPT 99205.

Figure 17. Median charge amounts for offices, urgent care centers and retail clinics for new
patient E&M codes, 2017

                                                     FH Healthcare Indicators and FH Medical Price Index 2019              23
When the same comparisons among retail clinics, urgent care centers and offices were made on the
basis of median allowed amounts, the results differed somewhat (figure 18). For CPT 99202, the office
had a lower median allowed amount ($66) than either urgent care center ($93) or retail clinic ($73), even
though the office median charge was higher than that of the retail clinic (figure 17). There was a greater
difference between office ($92) and urgent care center ($114) allowed amounts for CPT 99203 than
between their corresponding charges for that code. Whereas office median charges were higher than
urgent care center median charges for CPT 99204, office median allowed amounts ($140) were slightly
lower than urgent care center median allowed amounts ($143) for that code.

                                                                                                     $179 $178

                             $180

                             $160                                                 $140 $143

                             $140
     Median allowed amount

                                                                   $114
                             $120            $93             $92
                                                                          $85
                             $100                  $73
                                       $66
                             $80

                             $60

                             $40

                             $20

                               $0
                                          99202                   99203              99204*             99205*
                                                                     CPT procedure code

                                                         Office     Urgent Care    Retail Clinic

CPT Code                            Description
99202          Office outpatient – new – 20 minutes
99203          Office outpatient – new – 30 minutes
99204          Office outpatient – new – 45 minutes
99205          Office outpatient – new – 60 minutes
* Retail clinics did not have enough volume to establish any values for CPT 99204 or CPT 99205.

Figure 18. Median allowed amounts for offices, urgent care centers and retail clinics for new
patient E&M codes, 2017

                                                   FH Healthcare Indicators and FH Medical Price Index 2019      24
Telehealth
Telehealth usage has continued to rise as more states and regions implement laws facilitating it. National
growth of claim lines for telehealth was greater in the period 2012-2017 (1,202 percent) than in the period
2011-2016 reported last year (643 percent; figure 19). The rural increase in telehealth claim lines from
2012 to 2017 was 482 percent and the urban increase 1,289 percent. In the single year from 2016 to
2017, rural growth was 29 percent and urban growth 55 percent, with overall national growth 53 percent.
That national growth rate was higher than that of any other place of service studied for that variable in this
report. By comparison, from 2016 to 2017, national utilization of urgent care centers increased 14
percent, of retail clinics 7 percent and of ASCs 6 percent, while that of ERs decreased 2 percent.

                            50%

                            45%

                            40%
   Percent of claim lines

                            35%

                            30%

                            25%

                            20%

                            15%

                            10%

                            5%

                            0%
                                  2012   2013           2014           2015              2016       2017
                                                               Year

                                          Rural        Urban          Telehealth Total

Figure 19. Percent of claim lines with telehealth usage by rural, urban and national settings, 2012-
2017

                                         FH Healthcare Indicators and FH Medical Price Index 2019          25
Figure 20 shows claim lines with telehealth usage as a percentage of all medical claim lines by rural,
urban and national settings. In 2016 and 2017, urban telehealth claim lines were a larger percentage of
all medical claim lines in that setting than rural telehealth claim lines were in their setting. From 2016 to
2017, urban telehealth claim lines grew from 0.08 percent to 0.12 percent of all urban medical claim lines,
while rural telehealth claim lines grew from 0.04 percent to 0.05 percent. Nationally, from 2016 to 2017,
telehealth claim lines grew from 0.07 percent to 0.11 percent of all national medical claim lines.

                                                         0.14%

                                                         0.12%
   Percent of all medical claim lines for that setting

                                                         0.10%

                                                         0.08%

                                                         0.06%

                                                         0.04%

                                                         0.02%

                                                         0.00%
                                                                 2012       2013           2014             2015             2016   2017
                                                                                                   Year

                                                                              Rural        Urban          Telehealth Total

Figure 20. Claim lines with telehealth usage as a percentage of all medical claim lines by rural,
urban and national settings, 2012-2017

                                                                        FH Healthcare Indicators and FH Medical Price Index 2019           26
In 2017, the top five states for telehealth claim lines as a percentage of all medical claim lines in that
state, in order from most to least, were Oklahoma, Wyoming, Ohio, Hawaii and West Virginia (figure 21).
None were among the top five states in 2016. The bottom five states in 2017 for telehealth claim lines as
a percentage of all medical claim lines, in order from least to most, were New Jersey, Rhode Island,
Nebraska, Connecticut and South Dakota. One of these, South Dakota, was among the top five in 2016.

Figure 21. Percent of claim lines with telehealth usage compared to all medical claim lines by
state, 2017

                             FH Healthcare Indicators and FH Medical Price Index 2019                   27
As in 2016, telehealth was most associated with individuals aged 31-60, who accounted for 44 percent of
the distribution of claim lines with telehealth usage in 2017 (figure 22). Their share was smaller, however,
than the previous year’s 56 percent. Pediatric and young adult age groups made up larger shares than in
the previous year. For example, the age group 0-10 constituted 4 percent of the distribution in 2016 but
10 percent in 2017. The age group 23-30 made up 10 percent of the distribution in 2016 but 12 percent in
2017.

                             16%

                             14%

                             12%
    Percent of claim lines

                             10%

                             8%

                             6%

                             4%

                             2%

                             0%
                                   0 to 10 11 to 18 19 to 22 23 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 Over 80
                                                                          Age group

Figure 22. Claim lines with telehealth usage by age group, 2017

                                                   FH Healthcare Indicators and FH Medical Price Index 2019                  28
In 2017, as with retail clinics and urgent care centers, claim lines with telehealth usage were submitted
more for females than males in every age group except children aged 0-10 (figure 23). The average
differential across all age groups was 56 percent female to 44 percent male, which was slightly less than
the typical 60 percent/40 percent female/male distribution seen in all medical claim lines.

                Over 80

                71 to 80

                61 to 70

                51 to 60
    Age group

                41 to 50

                31 to 40

                23 to 30

                19 to 22

                11 to 18

                 0 to 10

                           0%   10%       20%          30%            40%      50%           60%   70%
                                                     Percent of claim lines

                                                    Male     Female

Figure 23. Claim lines with telehealth usage by age and gender, 2017

                                  FH Healthcare Indicators and FH Medical Price Index 2019               29
The top diagnostic categories associated with telehealth in 2017 were injury (e.g., contusions, open
wounds), acute respiratory infections and digestive system issues (e.g., gastroesophageal reflux disease,
abdominal and pelvic pain, nausea and vomiting), each of which constituted 13 percent of the distribution
of claim lines (figure 24). Neither injury nor digestive system issues had been among the top diagnostic
categories in 2016.

General signs and symptoms (e.g., fever, headache, general malaise) were the fourth most common
diagnostic category in 2017, accounting for nine percent of the distribution. Mental health reasons (e.g.,
anxiety disorders, stress reactions, obsessive-compulsive disorder), which had been the top telehealth
diagnostic category in 2016, were number five in 2017, at seven percent of the distribution.

                                                                           Injury
                                                                            13%
                      All Others
                         22%
Pregnancy Related
       2%                                                                                         Acute Respiratory
                                                                                                     Infections
                                                                                                        13%
Chronic Respiratory
       Disease
         2%
Skin Infections or
      Issues
        3%
Urinary Tract
  Infection                                                                                       Digestive System
     4%                                                                                                Issues
                                                                                                        13%
  Sprains, Strains,
Breaks and Fractures
        5%
                                                                                    General Signs and
            Joint/Soft Tissue                  Mental Health                           Symptoms
                 Issues                          Reasons                                  9%
                   7%                              7%

Figure 24. Distribution of claim lines with telehealth usage by diagnostic category, 2017

                                   FH Healthcare Indicators and FH Medical Price Index 2019                      30
Ambulatory Surgery Center
Claim lines for ASCs grew 97 percent overall from 2008 to 2017, the same rate documented in last year’s
report (97 percent from 2007 to 2016; figure 25). Growth was greater in urban (99 percent) than rural
areas (76 percent). From 2016 to 2017, claim lines with ASC usage decreased eight percent in rural
areas, increased seven percent in urban areas and increased six percent nationally.

                            16%

                            14%

                            12%
   Percent of claim lines

                            10%

                            8%

                            6%

                            4%

                            2%

                            0%
                                  2008   2009      2010     2011      2012          2013    2014   2015    2016   2017
                                                                             Year

                                                          Rural       Urban            ASC Total

Figure 25. Percent of claim lines with ASC usage by rural, urban and national settings, 2008-2017

                                                FH Healthcare Indicators and FH Medical Price Index 2019                 31
In each year in the period 2008 to 2017, ASCs accounted for less than one percent of all medical claim
lines by rural, urban and national settings (figure 26). But nationally, by the end of that period, ASCs had
nearly doubled as a percentage of all medical claim lines, from 0.46 percent in 2008 to 0.91 percent in
2017. In the rural setting, the growth in that period was from 0.48 percent to 0.84 percent of all medical
claim lines for that setting; in the urban setting, the increase was from 0.46 percent to 0.92 percent.

                                                         1.00%
   Percent of all medical claim lines for that setting

                                                         0.90%

                                                         0.80%

                                                         0.70%

                                                         0.60%

                                                         0.50%

                                                         0.40%

                                                         0.30%

                                                         0.20%

                                                         0.10%

                                                         0.00%
                                                                 2008   2009     2010       2011    2012    2013   2014     2015     2016   2017
                                                                                                        Year

                                                                                    Rural          Urban      ASC Total

Figure 26. Claim lines with ASC usage as a percentage of all medical claim lines by rural, urban
and national settings, 2008-2017

                                                                               FH Healthcare Indicators and FH Medical Price Index 2019            32
As with the other places of services studied for gender, more ASC claim lines were submitted for females
than males in almost every age group in 2017 (figure 27). But while retail clinics, urgent care centers and
telehealth had only one exceptional age group (0-10) in which males accounted for more of the claim line
distribution than females, ASCs had a second age group, 11-18. This pattern was also found for 2016 in
last year’s report.

                Over 80

                71 to 80

                61 to 70

                51 to 60
    Age group

                41 to 50

                31 to 40

                23 to 30

                19 to 22

                11 to 18

                 0 to 10

                           0%   10%          20%            30%              40%            50%   60%
                                                    Percent of claim lines

                                                   Male    Female

Figure 27. Claim lines with ASC usage by age and gender, 2017

                                 FH Healthcare Indicators and FH Medical Price Index 2019                33
Emergency Room
Claim lines for ERs grew nationally 194 percent from 2008 to 2017, less than the increase documented in
last year’s report (229 percent from 2007 to 2016; figure 28). Urban growth from 2008 to 2017 (196
percent) continued to be greater than rural growth (122 percent), as it had been from 2007 to 2016.

Despite the overall growth from 2008 to 2017, utilization decreased in the last year of that period,
particularly in rural areas. From 2016 to 2017, ER usage fell 10 percent in the rural setting, 1 percent in
the urban setting and 2 percent nationally.

                            18%

                            16%

                            14%
   Percent of claim lines

                            12%

                            10%

                            8%

                            6%

                            4%

                            2%

                            0%
                                  2008   2009    2010     2011       2012    2013    2014     2015     2016   2017
                                                                         Year

                                                Rural        Urban         Emergency Room Total

Figure 28. Percent of claim lines with ER usage by rural, urban and national settings, 2008-2017

                                                FH Healthcare Indicators and FH Medical Price Index 2019             34
In 2017, ERs accounted for a larger percentage of all medical claim lines than any of the other places of
service studied for that variable in this report (figure 29). Nationally, the ER percentage of all medical
claim lines grew from 0.9 percent in 2008 to 2.6 percent in 2017. By comparison, urgent care centers’
percentage of all medical claim lines nationally in 2017 was 1.2 percent. But growth in urgent care center
usage from 2008 to 2017 was much greater than that for ERs: 1,434 percent for urgent care centers,
more than seven times that of ERs (194 percent). This was a continuation of the trend from 2007 to 2016,
when urgent care center usage growth also had been more than seven times greater than ER growth.

In the rural setting, the ER percentage of all medical claim lines for that setting grew from 1.4 percent in
2008 to 3.1 percent in 2017. In the urban setting, the percentage grew from 0.9 percent to 2.5 percent.

                                                         4.5%
   Percent of all medical claim lines for that setting

                                                         4.0%

                                                         3.5%

                                                         3.0%

                                                         2.5%

                                                         2.0%

                                                         1.5%

                                                         1.0%

                                                         0.5%

                                                         0.0%
                                                                2008   2009     2010      2011      2012          2013   2014   2015     2016   2017
                                                                                                           Year

                                                                               Rural        Urban            Emergency Room Total

Figure 29. Claim lines with ER usage as a percentage of all medical claim lines by rural, urban and
national settings, 2008-2017

                                                                              FH Healthcare Indicators and FH Medical Price Index 2019                 35
As in 2016, the greatest number of claim lines with ER usage in 2017 was submitted for individuals in the
four age groups in the age range from 23 to 60, who accounted for 53 percent of all such claim lines,
nearly the same as the previous year’s 55 percent (figure 30). Within that age range in 2017, the highest
percentage of claim lines was attributed to individuals aged 51-60 (16 percent). As in 2016, pediatric
patients (0-18) constituted a relatively small share of the age distribution, 12 percent in 2017 compared to
15 percent in 2016.

                             16%

                             14%

                             12%
    Percent of claim lines

                             10%

                             8%

                             6%

                             4%

                             2%

                             0%
                                   0 to 10   11 to    19 to   23 to   31 to  41 to     51 to    61 to   71 to   Over 80
                                              18       22      30      40     50        60       70      80
                                                                       Age group

Figure 30. Claim lines with ER usage by age group, 2017

                                                     FH Healthcare Indicators and FH Medical Price Index 2019             36
As with all of the other places of service studied for gender, more claim lines with ER usage were
submitted for females than males in most age groups in 2017 (figure 31). The sole exception, as with
retail clinics, urgent care centers and telehealth, was the age group 0-10, in which claim lines for boys (56
percent) outnumbered those for girls (44 percent). In the age group 11-18, the disparity between females
(52 percent) and males (48 percent) was relatively small, but the gap widened over the age of 18.

                Over 80

                71 to 80

                61 to 70

                51 to 60
    Age group

                41 to 50

                31 to 40

                23 to 30

                19 to 22

                11 to 18

                 0 to 10

                           0%   10%          20%         30%          40%         50%            60%   70%
                                                       Percent of claim lines

                                                       Male    Female

Figure 31. Claim lines with ER usage by age and gender, 2017

                                      FH Healthcare Indicators and FH Medical Price Index 2019               37
Figure 32 shows the 2017 distribution of claim lines with ER usage by diagnostic category for individuals
over the age of 22, the age range that most commonly uses the ER. Acute respiratory infections were the
number one diagnostic category, with 16 percent of the distribution, followed by digestive system issues
(14 percent), general signs and symptoms (11 percent), joint/soft tissue issues (8 percent) and injury to
body (7 percent).

                             18%

                             16%

                             14%
    Percent of claim lines

                             12%

                             10%

                             8%

                             6%

                             4%

                             2%

                             0%

Figure 32. Distribution of claim lines with ER usage by diagnostic category for individuals over 22
years of age, 2017. Phrase with ellipse is “Injury, Poisoning and Certain Other Consequences of External
Causes.”

According to FAIR Health data, the diagnostic distribution differed somewhat for pediatric patients (aged
0-18) and college-age patients (aged 19-22). For both of those age groups, digestive system issues were
the number one diagnostic category, with acute respiratory infections in second place. In third place for
pediatric patients was head injury, and for college-age patients injury to body. General signs and
symptoms were in fourth place for both. In fifth place for pediatric patients was injury to body, and for
college-age patients, joint/soft tissue issues.

One diagnostic category common to all three age groups was “Injury, Poisoning and Certain
Consequences of External Causes,” ranking at number 8 for pediatric patients, number 12 for college-age
patients and number 15 for adults over 22. The top diagnoses in the category, however, varied by age

                                   FH Healthcare Indicators and FH Medical Price Index 2019            38
group. In pediatric patients, the diagnoses mostly consisted of foreign bodies in the alimentary tract,
respiratory tract and ear, and in college-age individuals of poisoning by or adverse effects of drugs such
as narcotics and psychodysleptics (hallucinogens). In adults over 22, foreign body in the alimentary tract
was the most common diagnosis in the category “Injury, Poisoning and Certain Consequences of
External Causes,” but complications of genitourinary prosthetic devices, implants and grafts were the
second most common diagnosis in that category.

For individuals in all age groups in 2017, the most common ER procedure, not including E&Ms, was
diagnostic radiology of the chest (e.g., chest X-rays), with 18 percent of the distribution of claim lines
(figure 33). Cardiography procedures (e.g., electrocardiograms) were second, with 15 percent of the
distribution. Diagnostic radiology of the head and neck (e.g., computed tomography [CT] scan of the head
or brain without contrast) and diagnostic radiology of the abdomen followed, each with eight percent.
Diagnostic radiology of the lower extremities was in fifth place with five percent.

                                                                                Diagnostic Radiology
                                All Others                                            Chest
  Diagnostic                       24%                                                 18%
  Ultrasound
 Procedures of
   the Pelvis
      2%

Organ or Disease-
 Oriented Panels
       3%                                                                                          Cardiography
                                                                                                    Procedures
Diagnostic Radiology                                                                                   15%
  Spine and Pelvis
        4%

 Hematology and                                                                          Diagnostic Radiology
  Coagulation                                                                               Head and Neck
   Procedures                                                                                    8%
       4%
Diagnostic Radiology        Chemistry                                       Diagnostic Radiology
                            Procedures       Diagnostic Radiology                Abdomen
 Upper Extremities
                                5%            Lower Extremities                     8%
        4%
                                                     5%

Figure 33. Distribution of claim lines with ER usage by procedures for individuals in all age
groups, not including E&Ms, 2017

                              FH Healthcare Indicators and FH Medical Price Index 2019                       39
Figure 34 shows average charges and allowed amounts for the most common ER procedure codes in
2017. The charges shown ranged from a high of $565 for CPT 99285, emergency department visit—high
severity—life threatening, to a low of $23 for CPT 93010, an electrocardiogram. The corresponding
allowed amounts were $303 and $11, respectively. (Electrocardiograms tend to have a low cost because
the technology has become easy to acquire at a low price.) Whereas several of the most common
procedures in the ER had average charges over $300, none of the most common ones in retail clinics did
(figure 8), and in urgent care centers, only one did: CPT 99204, office outpatient—new—45 minutes, with
an average charge of $308 (figure 16).

             $600   $565

             $500
                                  $450

             $400
                                                $338
                           $303
                                                                                                           $302
    Amount

                                         $252
             $300

                                                       $185
             $200
                                                                                              $150                $142

             $100                                                                                    $61
                                                                        $29 $12   $39
                                                              $23 $11                   $17

               $0
                    99285         99284         99283      93010     71010        71020       70450        74177
                                                          CPT procedure code

                                   Average Charge Amount            Average Allowed Amount

CPT                                                             CPT
Code           Description                                      Code        Description
        Emergency department visit - high
99285   severity - life threatening           71010    Single view chest X-ray
        Emergency department visit -
99284 high/urgent severity                    71020    Two view chest X-ray
        Emergency department visit - moderate
99283 severity                                70450    CT head/brain w/o contrast material
93010 Electrocardiogram                       74177    CT abdomen and pelvis; with contrast
Figure 34. Average charges and allowed amounts for the most common procedures performed in
ERs, 2017

                                     FH Healthcare Indicators and FH Medical Price Index 2019                            40
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